CVA (quick ED algorithm)

28 Oct

submitted by Amit Kumar, M.D.

Cerebrovascular Accident: First thoughts…

1) Monitor/stabilize ABCs > POCT glucose > rush to neuroimaging

2) CT/MRI DWI: to differentiate ischemic vs hemorrhagic

3a) If ischemic and within 4.5 hours of last normal: tPA (alteplase)

–0.9mg/kg: Load with 10% (0.09mg/kg) as an IV bolus over 1 minute, followed by 90% (0.81 mg/kg) gtt over 1h

3b) If ischemic and within 6 hours of last normal: endovascular thrombectomy


*tPA highly suggested for NIHSS 4-22. Check contraindications.

*Use modified NIHSS (on MDCalc, greater inter-rater reliability, easier)


Simultaneous thoughts:

-Have broad differential:

  • hypoglycemia
  • seizure/post-seizure todd’s paralysis
  • infection-induced
  • tox-induced
  • cardiogenic (ex: ACS/STEMI)


-No need to micromanage glucose. Reduce if >180 mg/dL, obviously treat if <50 mg/dL

-BP management:

  • If giving tPA (maintain BP <180/110), if not giving tPA (don’t treat unless >220/120).
  • Use titratable IV anti-HTN drugs like labetalol pushes or nicardipine gtt

-Other things that need to happen inpatient (not ED!): HLD panel, HbA1c, carotid dopplers, ECHO, counseling to quit smoking, starting anti-platelet agents (if given tPA, 24 hours after)



-Ischemic CVA:

-Modified NIHSS:

-tPA contraindications:

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